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School  Hygiene  in  Massachusetts 

BY 

GEORGE  H.'  MARTIN,  Secretary 


^’ieprinted  from  the  Seventy- second  Report  of  the  Massachusetts 
Board  of  Education 


SCHOOL  HYGIENE 


Containing  a Statement  relating  to  the  Present  Condition  of 
Medical  Inspection  in  the  Schools  of  Massachusetts ; 
Disclosures  by  School  Inspection;  Limita- 
^ tions  on  School  Work ; the  Teeth 

also 

Tuberculosis;  Suggestions  to  Teachers  regarding  Tubercu- 
losis and  its  Prevention ; Printed  Rules  of 
Health;  Out-door  Class  in  Boston 

BY 

GEORGE  H.  MARTIN 

Secretary  State  Board  of  Education 


BOSTON 

Wright  & Potter  Printing  Company,  State  Printers 
1 8 Post  Office  Square 
1909 


MEDICAL  INSPECTION. 


MEDICAL  INSPECTION. 


The  law  requiring  school  committees  or  boards  of  health  to 
appoint  school  physicians  was  amended  during  the  legislative 
session  of  1908  by  repealing  the  section  which  limited  the  ex- 
penditures to  a specific  appropriation  for  the  purpose.  This 
leaves  the  law  mandatory  upon  all  school  committees  in  towns 
and  upon  all  school  committees  in  cities  where  the  work  has  not 
been  taken  up  by  boards  of  health. 

Reports  received  show  that  in  294  of  the  321  towns  and  in 
32  of  the  33  cities  school  physicians  have  been  appointed  and 
are  now  at  w^ork. 

In  one  or  two  towns  it  appears  that  the  inspection  is  under  the 
direction  of  the  board  of  health.  This  is  not  in  accordance  with 
the  law.  Boards  of  health  are  authorized  to  appoint  school 
physicians  only  in  cities. 

In  a majority  of  cases  the  physicians  report  in  writing  to 
the  committees,  and  their  reports  are  printed  in  the  annual 
school  reports.  This  should  be  required  in  all  cases. 

The  reports  now  in  print  are  most  gratifying.  With  great 
unanimity  they  show  that  the  physicians  have  accepted  their 
appointment  in  the  highest  professional  spirit;  that  they  have 
entered  on  the  new  work  with  interest;  that  they  have  inter- 
preted the  law  broadly;  that  they  have  dealt  with  delicate  situ- 
ations with  tact  and  wisdom,  thereby  winning  the  confidence  of 
parents  and  teachers;  and  finally,  that  the  service  which  they 
have  rendered  is  in  most  cases  far  in  excess  of  their  pecuniary 
compensation. 

The  following  statement,  from  the  report  of  the  superin- 
tendent of  schools  of  Northampton,  is  typical  of  many : — 

Medical  inspection  in  the  Northampton  schools  is  an  unquahfied 
success.  This  is  largely  due  to  the  energy,  tact  and  practical  experience 
in  school  matters  of  our  school  physician,  Dr.  J.  G.  Hanson,  supple- 
mented by  the  cordial  co-operation  of  parents  and  teachers,  and,  most 
important  of  all,  the  professional  support  given  him  by  the  physicians, 
dentists  and  oculists  practising  in  this  city. 


4 


A part  of  the  work,  which  was  less  prominent  in  the  minds 
of  those  who  framed  the  law,  may  yet  prove  to  he  of  prime 
importance.  This  is  the  inspection  of  school  buildings  and 
premises.  In  many  of  the  reports  the  inspection  is  shown  to 
have  been  thorough,  and  the  conditions  as  to  light,  heat,  venti- 
lation and  sanitation  are  described  in  unmistakable  terms.  Im- 
provements which  neither  teachers  nor  superintendents  nor 
State  agents  have  been  able  to  secure  may  yet  be  brought  about 
through  the  fearless  exposures  by  the  school  doctors. 

The  possibilities  in  this  direction  are  shown  in  the  Ameshury 
report : — 


By  virtue  of  a law  passed  by  our  Legislature  of  1906,  a new  office 
in  the  management  of  our  schools  was  created.  Several  conditions, 
which  had  existed  some  time,  confronted  your  inspector,  and  needed 
immediate  attention.  The  work  of  the  year  has  been  looked  after 
thoroughly.  We  will  be  excused  of  any  egotism  if  we  say  the  results 
have  been  exceedingly  gratifying.  Of  course  only  a beginning  could 
be  accomplished  where  there  is  so  much  work  to  do. 

^ The  first  and  foremost  thing  to  do  was  to  remedy  the  condition  of 
things  at  the  Bartlett  school.  Here  was  a menace,  in  the  minds  of  the 
parents,  and  the  school  committee  was  at  a standstill  as  to  what  to  do. 
When  the  superintendent  wanted  to  transfer  pupils  from  one  school  to 
another,  he  had  to  respect  the  arguments  against  the  bad  health  condi- 
tions at  the  Bartlett. 

Diphtheria  had  made  its  appearance  there  so  often  (ten  or  twelve 
cases)  that  many  sessions  of  school  were  lost,  the  full  attendance 
lessened  and  the  school  efficiency  materially  inteiTupted.  The  drainap 
from  the  sink  was  found  to  be  bad,  — absolutely  no  idea  of  health  in 
its  construction.  A cesspool  was  sunk,  plumbing  established  in  ac- 
cordance with  the  regulations  of  the  board  of  health,  house  cleaned, 
fumigated,  and  then  a liberal  coat  of  oil  applied  to  all  the  floors.  Theie 
have  been  no  contagious  cases  from  that  school  since. 

For  years  (always,  for  that  matter)  contagious  diseases  have  occa- 
sionally broken  out  in  some  of  the  schools,  so  that  the  board  of  health 
had  to  destroy  many  dollars’  worth  of  books  and  other  school  property, 
discontinue  the  school  sessions,  clean,  wash  and  fumigate,  all  of  "which 
entailed  many  dollars  of  expense  to  the  tax  payer.  During  this  year 
not  a single  case  of  contagious  disease  has  made  its  appearance,  not 
a cent’s  worth  of  property  has  been  destroyed,  not  a session  of  school 
has  been  omitted,  and  the  board  of  health  are  strangers  to  us. 

The  reports  also  show  that  an  increasing  nnmher  of  children 
are  cared  for  by  the  parents  in  accordance  with  the  notification 


5 

cards  sent  from  the  school.  Yet  parental  neglect  still  stands 
in  the  way  of  securing  the  hoped-for  results.  Where  school 
nurses  are  employed,  the  children  are  cared  for  more  quickly 
and  better,  and  the  loss  of  school  time  is  reduced  to  a minimum. 
All  signs  point  to  the  fact  that  the  school  nurse  will  ultimately 
be  considered  an  essential  factor  in  the  school  system  of  all 
cities  and  large  towns. 

Eye  ato  Ear  Tests. 

The  second  annual  tests  of  sight  and  hearing  of  school  pupils 
have  been  made  by  the  teachers,  and  the  results  included  in  the 
school  returns.  Only  one  town,  ETantucket,  reports  that  the 
examination  was  not  made.  The  results  are  as  follows : — 


Eye  and  ear  tests. 


Counties. 

Number  of 

PUPILS  EXAMINED. 

Defective  eyes. 

Defective  ears. 

1907. 

1908. 

1907. 

1908.  i 

1907. 

1908. 

Barnstable,  .... 

4,562 

4,529 

770 

539 

276 

143 

Berkshire,  .... 

14,343 

14,653 

2,614 

2,470 

786 

593 

Bristol,  .... 

38,210 

37,957 

7,683 

6,700 

2,450 

1,802 

Dukes,  .... 

678 

752 

162 

162 

32 

43 

Essex,  ..... 

54,088 

53,252 

11,984 

9,308 

3,240 

2,326 

Franklin,  .... 

6,546 

6,925 

1,343 

1,077 

520 

397 

Hampden,  .... 

26,749 

27,458 

5,275 

4,761 

1,749 

1,750 

Hampshire,  .... 

8,807 

8,650 

1,626 

1,510 

535 

407 

Middlesex,  .... 

92,688 

93,567 

19,975 

16,839 

5,495 

3,902 

Nantucket,  .... 

- 

- 

- 

- 

- 

- 

Norfolk 

26,525 

27,800 

4,498 

4,342 

1,465 

1,254 

Plymouth,  .... 

20,818 

21,1651 

3,295 

2,9341 

911 

8191 

Suffolk 

93,920 

92,463 

28,853 

21,950 

7,324 

6,805 

Worcester,  .... 

44,530 

48,264 

8,529 

8,566 

2,604 

2,360 

State,  .... 

432,464 

437,435 

96,607 

81,158 

27,387 

22,601 

1 Exclusive  of  Hanson. 


While  the  number  of  children  examined  in  1908  is  slightly 
larger  than  the  number  in  1907,  the  number  found  defective 
appears  to  be  decidedly  smaller.  In  1907,  22.3  per  cent,  of 
those  examined  were  found  to  be  defective  in  vision  and  6.3 


6 


per  cent,  in  hearing.  The  number  reported  in  1908  as  defective 
in  vision  is  18.5  per  cent,  and  in  hearing  5.1  per  cent. 

It  is  impossible  at  present  to  account  for  this  apparent  re- 
duction. Whether  it  is  dne  to  more  careful  testing,  or  to  a 
different  basis  for  reporting,  or  to  counting  children  wearing 
glasses  as  normal,  no  one  can  tell;  hut  it  is  interesting  to  note 
that  there  appears  to  he  a reduction  in  every  county.  The 
figures  for  another  year  may  throw  some  light  upon  the  subject. 

Disclosuees  by  School  Inspection. 

The  number  of  children  suffering  from  some  physical  ailment 
is  shown  to  he  much  greater  than  any  one  had  supposed.  This 
is  true  of  the  country  towns  as  well  as  of  the  cities.  In  a small 
country  school  were  found  an  epileptic  child,  one  with  serious 
spinal  curvature  and  one  with  quite  pronounced  chorea.  A 
school  physician,  who  has  inspected  330  children  in  two  country 
towns,  reports : — 

Of  these,  217,  or  65  per  cent.,  had  decayed  teeth;  65,  or  nearly  20 
per  cent.,  had  adenoids  and  chronically  enlarged  tonsils;  9 had  decided 
eczema ; 5 had  valvular  lesions  of  the  heart ; 7 had  head  lice ; and  1 had 
spinal  curvature. 

In  view  of  these  facts,  the  statement  frequently  made  as  an 
excuse  for  non-action  on  the  part  of  school  committees,  Our 
children  are  all  healthy,’’  is  evidently  founded  on  ignorance. 

In  the  cities  the  number  of  children  affected  and  the  variety 
of  ailments  is  large.  In  AVorcester  the  school  inspectors  found 
the  following : — 


Diseases. 

Cases. 

Specific  infectious  diseases,  ...... 

269 

Diseases  of  the  oral  and  respiratory  tract, 

1,974 

Diseases  of  the  ear,  ...... 

75 

Diseases  of  the  eye,  ....... 

223 

Diseases  of  the  skin,  ....... 

2,109 

Miscellaneous  diseases,  ...... 

1,4J02 

In  Boston  the  inspectors  found : — 


Diseasks, 

Ca.se.s. 

Specific  infectious  diseases,  ...... 

408 

Diseases  of  the  oral  and  respiratory  tract, 

1,932 

Diseases  of  the  ear,  ....... 

213 

Diseases  of  the  eye,  ....... 

1,067 

Diseases  of  the  skin,  ....... 

4,497 

Miscellaneous  diseases,  ...... 

1,368 

I have  used  these  two  cities  as  types.  one  would  be 

willing  to  vouch  for  these  figures  as  showing  the  exact  physical 
condition  of  all  the  school  children  in  these  cities.  The  inspec- 
tions vary  in  their  thoroughness,  the  physicians  vary  in  their 
diagnoses,  and  the  categories  used  in  classification  are  not  ex- 
actly alike  in  their  content.  But  what  the  figures  do  show  is, 
that  a large  number  of  children  are  in  school  who  were  not  at 
the  time  of  inspection  well. 

Limitations  on  School  Work. 

There  is  always  in  the  public  mind  a feeling  of  dissatisfaction 
with  the  results  of  educational  work.  Such  feeling  finds  voice 
in  private  circles,  on  public  platforms  and  in  periodical  litera- 
ture. The  voices  are  more  numerous  and  more  strident  at  some 
periods  than  at  others,  but  the  feeling  always  exists  and  has 
always  existed,  and  lies  at  the  foundation  of  all  educational 
reform.  The  dissatisfaction  has  not  been  without  justification. 
The  schools  have  not  secured  all  the  results  desired.  The  money 
expended  has  not  brought  the  return  which  the  public  had  a 
right  to  expect.  These  facts  cannot  be  concealed  nor  truthfully 
denied. 

In  looking  for  the  cause  or  causes  of  the  inadequate  returns 
yielded  by  the  schools,  most  of  the  speakers  and  writers  have 
gone  far  astray.  They  have  almost  without  exception  confined 
their  view  to  the  schools  as  institutions,  — that  is,  to  the  admin- 


8 


istration,  to  the  teaching,  or  to  the  curriculum.  J^ever  has  one 
of  them  taken  account  of  the  fundamental  factor  in  the  prob- 
lem, — the  children  themselves.  The  assumption  in  all  these 
discussions  has  been  that  children,  being  children,  are  equally 
susceptible  to  education ; that  they  will  take  ’’  learning  as  they 
take  diseases  peculiar  to  children,  if  they  are  properly  “ ex- 
posed ” to  it. 

Medical  inspection  has  given  a rude  jolt  to  this  assumption. 
It  has  shown  that  in  the  cases  of  large  numbers  of  children  there 
is  no  reasonable  ground  for  expectation  that  they  will  come  out 
of  the  schools  scholars.  In  the  cases  of  many  we  have  no  right 
to  expect  to  develop  a high  degree  of  intelligence.  One  phy- 
sician’s report  says,  I found  fourteen  children  who  were  men- 
tally deficient,”  that  is,  too  weak  minded  to  profit  by  school 
instruction.  But  of  children  of  normal  mental  powers  the  num- 
ber of  children  suffering  from  physical  ailments  is  large  enough 
to  lower  the  standard  of  attainment  of  the  whole  school  popula- 
tion. Take,  for  example,  some  of  the  cases  classed  under  mis- 
cellaneous diseases. 

According  to  the  Boston  report  for  1906,  the  inspectors  found 
208  cases  which  they  called  anremia.  If  there  had  been  so 
many  cases  of  diphtheria,  everybody  would  have  been  alarmed, 
• — teachers,  parents,  doctors  and  the  public.  But  only  anaemia, 
— merely  pallor  and  weakness  and  languor,  — and,  perhaps, 
some  functional  disturbance,  no  one  makes  much  account  of 
these,  and  the  school  machinery  grinds  on. 

If  the  study  of  physiology  has  taught  anything,  it  is  that  for 
all  mental  activity  one  thing  is  essential,  — an  adequate  supply 
of  good  red  blood.  Fancy  an  anaemic  girl  sitting  down  at  night 
to  a difficult  lesson  in  arithmetic  or  geometry  or  Latin,  trying 
to  concentrate  her  thouglit,  summoning  powers  which  cannot 
respond  to  her  call.  Her  inevitable  failure  is  not  a failure  in 
the  teaching,  or  in  the  curriculum,  or  in  the  disposition  of  the 
girl ; it  is  simply  a failure  to  coerce  nature  to  a reversal  of  her 
laws. 

AVhat  is  true  of  anaemic  pupils  is  equally  true  of  huudreds 
reported  as  suffering  from  neuralgia.  There  is  no  possibility 
of  successful  and  continuous  intellectual  effort. 

In  view  of  what  medical  inspection  has  already  shown,  we 
have  a right  to  insist  that  Avhen  the  results  of  school  woi‘k  arc 


9 


measured,  men  should  judge  righteous  judgment.  There  is 
much  popular  clamor  for  the  essentials  ” in  public  schools. 
Modern  business  has  become  so  highly  systematized  and  special- 
ized that  the  business  man  expects  every  employee  to  work  with 
the  promptness  and  unerring  accuracy  of  a standardized  ma- 
chine ; anything  less  than  this  causes  annoyance. 

If  the  schools  could  receive  from  the  homes  children  sound 
in  body  and  clean  in  personal  habits,  these  children  would  go 
out  able  to  read  and  write  and  spell  and  cipher  to  everybody’s 
satisfaction,  without  leaving  out  anything  from  the  present 
curriculum. 

The  essential  which  is  lacking  is  a condition  of  body  which 
makes  concentrated  and  sustained  mental  effort  not  only  a possi- 
bility, but  a delight.  As  this  condition  is  approximated,  the 
schools  will  have  approximate  success. 

The  whole  situation  is  aggravated  by  the  facts  which  a recent 
investigation  in  Hew  York  has  shown,  — that  the  physical  de- 
fects are  most  numerous  in  the  earlier  years  of  school  life. 
Children  outgrow  many  of  their  troubles.  While  there  is  some 
comfort  in  knowing  this,  school  people  will  at  once  see  that 
the  period  when  defects  are  most  numerous  is  the  period  when 
in  the  lower  grades  most  of  the  mechanical  work  is  done,  which 
is  the  foundation  for  all  subsequent  study.  This  is  the  time 
when  children  are  learning  to  read  and  to  write  and  to  spell  and 
to  handle  numbers,  — the  time  when  habits  of  accuracy  are 
formed,  if  formed  at  all.  It  is  the  time  for  drill. 

The  facts  shown  in  the  chapter  on  Retardation  and  Physical 
Defects,”  in  the  book,  Medical  Inspection  of  Schools,”  pre- 
pared by  Dr.  Luther  Hasley  Gulick  and  Mr.  Leonard  P.  Ayres, 
and  published  by  the  Hew  York  Charities  Publication  Com- 
mittee, are  most  significant. 

The  Teeth. 

Examinations  of  the  teeth  of  school  children  in  different 
places  throw  light  upon  the  primary  cause  of  many  of  the  dis- 
abilities under  which  children  suffer. 

A paper  read  by  Dr.  C.  Edward  Wallis  at  the  London  Con- 
gress of  School  Hygiene  in  1907,  and  published  in  the  second 
volume  of  the  proceedings,  contains  a table  showing  the  results 
of  an  examination  of  245  children  between  the  ages  of  seven  and 


10 


twelve  in  an  elementary  school  in 

one  of 

the  poorer  districts 

of  London : — 

Totals. 

Number  examined,  . . . . 

245  children. 

Number  of  decayed  temporary  teeth, 

952  = 

average  per  child,  3.9. 

Number  of  decayed  permanent  teeth. 

685  = 

average  per  child,  2.8. 

Alveolar  abscesses  and  fistulae  discharging 

pus, 

23  = 

9 . 3 per  cent. 

Chronic  pharyngitis,  .... 

40  = 

16.3  per  cent. 

Chronic  enlargement  of  tonsils, 

71  = 

29.0  per  cent. 

Chronic  submaxillary  lymphadenitis  (en- 

larged glands  under  the  jaw), 

150  = 

62.2  per  cent. 

Enlarged  glands  in  neck, 

16  = 

6 . 5 per  cent. 

‘‘Mouth-breathers,’^  . . 

6 = 

2 . 4 per  cent. 

Ansemia  (22  boys,  66  girls),  . 

88  = 

37  per  cent.  (13.4  boys, 

81.4  girls). 


Strasburg  was  the  first  city  in  the  world  to  maintain  a munic- 
ipal school  dentistry.  Dr.  Jessen,  in  a paper  read  at  the  London 
Congress,  reports  of  this  work ; — 

In  no  part  of  the  public  medical  service  have  such  results  been  ob- 
tained with  such  small  expense.  The  experience  of  the  Strasburg  and 
other  experiments  has  proved  beyond  doubt  that  the  health  of  the 
children  has  been  gTeatly  raised  by  dental  treatment.  The  care  of  the 
teeth  has  guarded  against  infectious  diseases,  and  been  a most  valuable 
factor  in  the  struggle  against  the  spread  of  tuberculosis.  . . . 

The  report  of  the  government  inspector  laid  stress  on  the  following 
facts : — 

School  absences  caused  by  toothache  had  greatly  diminished. 

The  work  of  children  hitherto  suffering  from  their  teeth  had  greatly 
improved. 

The  general  health  of  children  who  occasionally  suffered  from  tooth- 
ache had  greatly  improved,  as  a consequence  of  dental  treatment. 

Very  little  school  time  had  been  lost  by  children  attending  school 
dentistries,  as  they  went  out  of  school  hours.  . . . 

The  children  took  the  greatest  interest  in  the  instruction  given  to 
them  about  the  care  of  their  teeth. 

The  children  like  to  be  treated  by  the  dentist,  and  no  objections 
whatever  had  been  experienced  on  the  part  of  the  parents. 

Dr.  Jessen  made  this  statement:  In  Germany  at  the  present 
moment  at  least  90  per  cent,  of  all  elementary  school  children 
suffer  from  decayed  teeth.” 

That  conditions  are  not  much,  if  any,  better  in  Massachu- 
setts, seems  probable,  judging  from  some  reports  recently  made. 


11 


The  school  physician  of  Ashby  reports  that  95  per  cent,  of 
school  children  have  decayed  teeth. 

The  school  physician  of  ISTorthampton  reports  as  follows:  — 

The  most  deplorable  fact  elicited  from  the  examination  was  the 
almost  total  lack  of  care  given  children’s  teeth.  Out  of  600  children 
whose  teeth  were  examined,  only  74  had  received  any  attention,  and  the 
larger  number  of  the  526  exhibited  most  uncleanly  and  unhealthy 
mouths. 

Dr.  Willard  C.  Crocker,  medical  inspector  of  the  schools  of 
Foxborongh,  gives  in  his  report  a table  of  the  results  of  inspec- 
tion in  all  the  schools  of  that  town : — 


School. 

Number 

examined. 

Teeth  needing 
to  be  filled. 

Teeth  to  be 
extracted. 

High, 

69 

268 

141 

Grade  IX., 

43 

147 

26 

Grade  Vm.,  . . . . 

48 

166 

25 

Grade  VII., 

51 

162 

31 

Grade  VI., 

31 

81 

11 

Grade  V.,  ..... 

36 

103 

45 

Grade  IV.,  ..... 

36 

47 

20 

Grade  III., 

39 

71 

8 

Grade  II., 

31 

38 

- 

Grade  I.,  ....  . 

40 

8 

3 

Cary  school,  ..... 

30 

38 

6 

Quaker  Hill  school. 

24 

33 

2 

Everett  school,  .... 

14 

26 

1 

Plimpton  school,  .... 

IS 

31 

- 

Pratt  school,  .... 

• 26 

48 

5 

Paine  school, ..... 

36 

36 

10 

Totals,  ..... 

572 

1,303 

334 

j 


12 


A striking  feature  of  this  exhibit  is  the  condition  of  the  teeth 
of  the  pupils  in  the  high  school.  There  is  no  reason  to  think 
that  the  condition  is  worse  in  this  town  than  in  others. 

It  would  be  easy  to  satirize  a condition  which  keeps  boys 
and  girls  in  high  school  at  work  five  hours  a day  for  four  years 
on  Latin  and  French  and  algebra  and  chemistry  and  a dozen 
other  subjects,  and  leaves  them  ignorant  of  the  elementary  prin- 
ciples of  health  and  without  habits  of  personal  cleanliness. 

That  faithful  inspection  and  frank  reporting  of  the  results 
will  bring  relief  is  evident  from  Dr.  Crocker’s  report : — 

Though  the  examination  and  report  sent  to  each  parent  showed  the 
defects  of  the  milk  teeth,  the  above  summary  refers  only  to  the  adult 
teeth,  and  does  not  include  teeth  already  filled  or  missing.  . . . 

All  agree  on  the  necessity  of  checking  the  decay  that  is  started; 
and  we  are  pleased  to  announce  that  the  dentists  of  Foxborough  have 
united  in  granting  a discount  of  25  per  cent,  from  the  regular  prices 
upon  all  work  for  the  school  children  as  outlined  in  this  examination, 
and  that  in  some  cases  a special  discount  may  be  arranged  on  recom- 
mendation of  the  medical  inspector. 

It  looks  as  if  through  dental  inspection  we  were  getting  nearer 
the  root  of  many  of  our  school  difficulties.  For  this  reason  the 
propaganda  started  by  the  Massachusetts  Dental  Council  is  most 
welcome.  The  travelling  exhibit  which  has  been  prepared  and 
the  popular  lectures  which  accompany  it  are  proving  effective 
means  of  arousing  public  interest. 

Tuberculosis. 

The  Legislature  of  1908  (chapter  181)  added  ^^tuberculosis 
and  its  prevention  ” to  the  legal  requirements  for  school  instruc- 
tion, so  that  the  law  now  reads:  — 


In  each  of  the  subjects  of  physiology  and  hygiene,  special  instruction 
as  to  the  effects  of  alcoholic  drinks  and  of  stimulants  and  narcotics  on 
the  human  system,  and  as  to  tuberculosis  and  its  prevention,  shall  be 
taught  as  a regular  branch  of  study  to  all  pupils  in  all  schools  which 
are  supported  wholly  or  partly  by  public  money,  except  schools  which 
are  maintained  solely  for  instruction  in  particular  branches.  . . . 

In  order  that  the  teachers  might  have  some  authoritative  guide 
in  carrying  out  the  provisions  of  the  law,  the  secretary  of  tlie 


( 


13 


Board  of  Education  through  the  courtesy  of  Dr.  Kobert  W. 
Lovett  of  Boston  was  able  to  confer  with  several  prominent 
specialists  in  pulmonary  diseases,  who  agreed  to  prepare  a simple 
booklet  of  suggestions  to  teachers.  This  was  done,  and  copies 
have  been  furnished  to  all  the  teachers  of  the  State.  The  con- 
tents are  as  follows : — 


Suggestions  to  Teachers  regarding  Tuberculosis  and  its  Pre- 
vention. 

The  suggestions  to  teachers  contained  in  this  booklet  have  been  pre- 
pared for  the  Board  of  Education,  as  a matter  of  public  service,  by  the 
following  eminent  specialists  of  Boston : — 


Arthur  T.  Cabot,  M.D.,  Chairman  Massachusetts  Commission  on  Hos- 
pitals for  Consumptives. 

Herbert  C,  Clapp,  M.D.,  Professor  of  Pulmonary  Diseases,  Boston  Uni- 
versity School  of  Medicine. 

Edward  O.  Otis,  M.D.,  Professor  of  Pulmonary  Diseases,  Tufts  College 
Medical  School. 

Horace  D.  Arnold,  M.D.,  Professor  of  Clinical  Medicine,  Tufts  College 
Medical  School. 

Cleaveland  Floyd,  M.D.,  Director,  Out-patient  Clinic,  Boston  Consump- 
tives’ Hospital. 

John  B.  Hawes,  2d,  M.D.,  Secretary  Massachusetts  Commission  on  Hos- 
pitals for  Consumptives. 

George  H.  Martin, 

Secretary. 


Introduction, 


Chapter  181  of  the  Acts  of  the  Commonwealth  of  Massachusetts  of 
1908  provides  that  tuberculosis  and  its  prevention  shall  be  taught  in  all 
grades  of  the  public  schools  of  this  State  in  which  instruction  is  given 
in  the  subjects  of  physiology  and  hygiene.  This  pamphlet  is  not  in- 
tended as  a text-book  for  teachers  of  this  subject,  but  is  merely  to 
suggest  certain  lines  of  instruction  and  to  emphasize  certain  points  to 
be  dwelt  on  with  particular  emphasis.  At  the  end  of  this  pamphlet  will 
be  found  references  to  various  standard  works  on  this  subject,  some 
of  which  will  be  within  the  reach  of  every  school  teacher,  or  which  can 
be  secured  at  a nominal  price. 

It  is  manifest  that  the  methods  of  teaching  and  the  subjects  which 
are  taught  must  vary  a gTeat  deal,  according  to  the  age  of  the  pupils. 
Among  the  primary  grades,  for  instance,  it  should  be  made  clear  in  the 
first  place  what  consumption  is,  and  why  it  is  necessary  to  know  some- 
thing about  it;  and  then  particular  emphasis  should  be  given  to  the 
question  of  home  hygiene,  fresh  air,  open  windows  at  night,  bathing, 
care  of  the  teeth,  proper  clothing,  proper  food,  the  avoidance  of  tea, 
coffee  and  tobacco,  etc.  Pupils  in  the  grammar  schools  should  be  taught 


J 


14 


more  than  this,  — they  should  be  given  some  idea  as  to  what  this  disease 
is  doing  in  our  midst,  what  causes  it,  and  the  methods  which  are  being 
taken  to  combat  it.  In  the  high  schools  and  normal  schools  instruction 
should  go  still  further,  and  it  is  possible  that  the  teachers  or  head 
masters  can  make  arrangements  with  the  school  physicians,  or  with 
physicians  of  local  anti-tuberculosis  associations,  to  give  a series  of 
short  talks  on  this  subject.  Students  of  this  age  should  not  be  allowed 
to  finish  their  training  without  having  a very  clear  idea  in  regard  to 
consumption,  its  cause,  the  methods  of  prevention  and  cure,  the  present 
campaign  against  it,  the  methods  of  treatment  in  the  sanatorium  and 
especially  in  the  home,  and,  most  important  of  all,  the  early  signs  and 
symptoms  of  this  disease,  as  well  as  a thorough  knowledge  of  the 
ordinary  laws  of  health  and  hygiene.  It  would  be  well  if  every  such 
pupil  was  required  to  read  Dr.  Knopf's  excellent  essay,  entitled  “ Tuber- 
culosis as  a Disease  of  the  Masses,  and  how  to  combat  it,"  which  can 
be  bought  for  25  cents,  or  which  can  be  secured  in  the  local  library. 

Every  teacher  should  realize  her  opportunity  in  thus  directing  her 
pupils  in  the  way  of  wholesome  living.  A healthy  mind  requires  a ♦ 
healthy  body.  The  interest  of  the  scholars  will  be  aroused  in  this 
matter  only  in  so  far  as  the  instructor  stimulates  or  develops  this 
interest. 

Outline. 

I. 

What  tuberculosis  is.  What  consumption  is.  What  the  tubercle  bacillus 
is.  When  discovered,  and  by  whom.  Methods  of  growth.  Things  favorable 
to  its  growth.  Things  unfavorable  to  its  growth. 

IT. 

Outline  of  history  of  tuberculosis:  (1)  ancient  times;  (2)  dark  ages; 

(3)  present. 

III. 

What  tuberculosis  does:  (a)  in  the  world;  (b)  in  this  country;  (c)  age 
at  which  it  kills;  (d)  compared  with  other  great  disasters, — yellow  fever, 
Slocum  disaster,  San  Francisco  fire.  Civil  War. 

IV. 

How  tuberculosis  is  spread.  Sputum ; milk ; anti-spitting  laws. 

V. 

Tuberculosis  is  preventable;  it  is  curable;  it  is  not  hereditary.  How  pre- 
vented: (a)  by  living  so  as  to  keep  health,  — fresh  air,  — exercise,  — food, 
etc.;  (b)  non-spitting. 

VI. 

How  cured,  — sanatoria.  Home  treatment.  Methods  of  getting  fresh 
air.  A cure  possible  in  any  climate.  A tendency  and  not  the  disease  is 
hereditary. 


( 


o 


15 


VII. 

Early  signs  and  symptoms  of  consumption.  Importance  of  other  things 
besides  a cough,  — pallor,  angemia,  loss  of  weight,  weakness,  listlessness, 
uncleanliness,  glands,  etc. 

VIII. 

The  campaign  against  consumption  in  Massachusetts.  Every  one  must 
do  his  share.  Tuberculosis  exhibits,  societies,  hospitals,  etc. 

IX. 

Reference  to  standard  works  on  the  subject. 

Tuberculosis  and  its  Prevention. 

I. 

Tuberculosis  is  a disease  caused  by  a very  small  germ  or  microbe 
called  the  tubercle  bacillus.  This  is  so  small  that  it  takes  three  thou- 
sand put  end  to  end  to  measure  one  inch.  This  germ  does  not  readily 
grow  outside  of  living  bodies,  but  when  it  gains  entrance  into  the  body 
it  grows  and  multiplies,  and  finally  destroys  the  tissues,  and  thus  causes 
the  disease  tuberculosis. 

Consumption  is  tuberculosis  of  the  lungs,  otherwise  known  as  pul- 
monary tuberculosis,  pulmonary  consumption,  or  phthisis.  Tubercu- 
losis of  other  parts  of  the  body  is  known  by  different  names,  such  as 
humpback,  or  PotCs  disease,  which  is  tuberculosis  of  the  spine;  hip 
disease,  tuberculosis  of  the  hip;  white  swelling  of  the  knee  or  of  the 
ankle,  which  is  tuberculosis  of  the  knee  or  of  the  ankle;  scrofula,  which 
so  many  children  have,  characterized  by  lumps  in  the  neck  caused  by 
enlarged  glands,  which  is  nothing  but  tuberculosis  of  these  glands;  lupus, 
a skin  disease,  tuberculosis  of  the  skin.  So  it  is  possible  for  this  tiny 
genn  to  cause  tuberculosis  or  tuberculous  disease  of  any  part  of  the 
human  body. 

Although  this  germ  cannot  grow  outside  of  the  body,  yet  it  will 
survive  and  keep  its  vitality  for  a considerable  time  after  it  is  cast  out. 
Darkness*  and  damp  favor  its  survival.  Dryness,  fresh  air  and  sunlight 
tend  to  destroy  it.  Direct  sunlight  will  kill  any  germ  of  tuberculosis  in 
twenty  minutes. 

The  organism  which  causes  this  disease  was  discovered  by  a famous 
German  physician.  Dr.  Robert  Koch,  in  1882.  Up  to  that  time  nobody 
knew  what  Tvas  the  cause  of  this  terrible  affliction. 

II. 

Tuberculosis  is  a very  old  disease.  Indeed,  in  the  old  Egyptian  mum- 
mies evidences  of  tuberculosis  have  been  discovered;  and  the  famous 
writei's  of  the  old  days,  whose  wulting-s  are  still  in  existence,  described 
this  strange  .condition,  in  which  their  patients  developed  a cough  and 
gradually  wasted  away.  The  disease  was  known  then,  as  it  is  now. 


) 


16 


as  the  “ Great  White  Plague.’’  There  was  not  much  which  they  could  do 
for  it.  A few  of  the  wiser  doctors  advised  their  patients  to  go  to  the 
mountains  or  to  take  a sea  trip,  although  they  could  not  explain  why 
this  should  be  beneficial. 

Later,  in  that  period  in  the  history  of  Europe  known  as  the  dark 
ages,  — the  tenth,  eleventh  and  twelfth  centuries,  — even  the  little 
knowledge  which  men  possessed  about  tuberculosis  was  forgotten,  and 
the  disease  swept  through  Europe,  destroying  people  by  thousands 
and  sometimes  wiping  out  whole  families.  Those  suffering  from  this 
disease  were  shunned  and  avoided  as  if  they  were  lepers,  and  were 
confined  in  rooms  wuth  the  windows  and  doors  closed,  shutting  out  fresh 
air  and  sunlight,  — things  which  we  now  know  are  so  important  in 
curing  the  disease. 

In  the  first  half  of  the  nineteenth  century  people  began  to  realize 
that  consumption  was  curable.  In  Germany  they  began  to  build  hos- 
pitals or  sanatoria  for  consumption,  where  those  suffering  from  this 
disease  could  be  sent  and  undergo  the  out-door  treatment,  remaining  in 
the  fresh  air  all  the  time,  eating  proper  food,  and  thus  have  their 
disease  cured.  This  plan  of  the  open-air  treatment  has  spread  over 
the  entire  world.  Now  a person  with  consumption  is  no  longer  given 
up  as  hopeless,  but  in  the  various  hospitals  and  sanatoria  which  are 
scattered  all  over  our  country,  and  especially  in  Massachusetts,  — the 
leader  in  this  movement,  — as  well  as  in  the  homes  of  the  people,  con- 
sumption is  being  cured. 

III. 

While  consumption,  then,  is  curable,  it  is  still  a very  prevalent  disease 
and  is  causing  incalculable  suffering  and  loss,  chiefly  because  it  is  greatly 
neglected.  It  has  been  found  that  of  all  people  who  die  every  year, 
about  one-seventh  die  from  consumption.  When  we  consider  the  terrible 
carnage  in  the  destructive  battles  in  the  eighteenth  century  we  are 
rightly  shocked,  and  yet  during  that  same  period  nearly  twice  as  many 
died  from  tuberculosis.  In  this  century,  during  the  four  years  of  the 
civil  war  there  were  killed  some  one  hundred  and  fifty  thousand  men, 
which  causes  one  to  realize  the  terrible  nature  of  war;  and  yet  evei-y 
year  in  the  United  States  there  are  more  than  one  hundred  and  fifty 
thousand  people  destroyed  by  this  one  preventable  disease,  — con- 
sumption. The  combined  sum  of  all  those  who  die  of  typhoid  fever, 
appendicitis,  scarlet  fever,  measles,  diphtheria  and  cancer  does  not 
begin  to  equal  the  number  that  die  from  consumption  alone.  Such 
comparisons  as  these  bring  us  to  a realizing  sense  of  the  part  played  by 
consumption  in  producing  misery  and  suffering  in  the  world. 

Most  important  of  all  is  the  fact  that  this  disease  attacks  people 
when  they  are  in  the  prime  of  their  life,  and  when  their  services  are  worth 
most  to  their  families  and  to  the  community  in  which  they  live;  for 
the  mortality  from  consumption  is  the  greatest  during  the  most  active 
period  of  life,  — from  fifteen  to  thirty-five  or  forty  years.  It  spares 


( 


17 


no  one,  neither  the  child,  the  youth  or  the  adult,  the  weak  or  the  strong. 
Compare  this  with  the  infectious  diseases  of  childhood,  such  as  diph- 
theria, scarlet  fever,  etc.,  which  are  most  prevalent  and  fatal  in  the 
early  years  of  life,  and  with  cancer,  which  is  rarely  fatal  before  a person 
is  fifty  years  old,  when  one  has  lived  longer  than  the  average  length 
of  human  life. 

During  the  past  five  or  six  years  there  have  been  certain  great  disasters 
which  have  aroused  the  sympathy  of  the  entire  country,  and  for  which 
relief  funds  have  been  raised  amounting  to  thousands  of  dollars:  for 
instance,  the  yellow  fever  epidemic  in  Louisiana  some  years  ago;  the 
terrible  Slocum  disaster  in  New  York  harbor;  and  the  San  Francisco 
earthquake  and  fire.  And  yet,  terrible  as  these  events  seemed  at  the 
time,  when  they  are  compared  with  what  consumption  is  doing  silently 
and  quietly  in  our  midst,  their  importance  sinks  into  insignificance. 

IV. 

When  the  germ  of  consumption  attacks  any  person,  it  gets  into  his 
lungs  and  there  grows  and  multiplies.  As  the  disease  becomes  active  a 
cough  develops,  and  the  person  afflicted  raises  a certain  amount  of 
sputum.  In  this  sputum  are  an  innumerable  number  of  the  tuberculosis 
germs,  which,  if  they  are  inhaled  by  people  run  down  or  otherwise  in  a 
poor  condition  to  resist  disease,  may  cause  the  disease  in  them  also. 
This  sputum  must  be  destroyed  in  every  case.  If  all  sputum  from  con- 
sumptives were  destroyed,  consumption  would  soon  die  out.  The  disease 
is  spread  by  carelessness  or  ignorance  on  the  part  of  the  consump- 
tives, who  do  not  realize  that  every  time  they  fail  to  destroy  the  sputum, 
or  spit  on  the  floor,  or  on  the  sidewalk,  it  will  dry,  be  ground  up  into  a 
powder,  fly  through  the  air  as  dust,  and  be  inhaled  by  some  person  who 
is  in  a condition  to  receive  the  disease,  and  so  cause  the  disease  in  him. 
It  has  been  calculated  that  in  the  sputum  of  one  consumptive  in  the 
course  of  twenty-four  hours  there  may  be  more  than  twenty-four  mil- 
lion of  these  germs. 

It  is  for  this  reason  that  a law  has  been  made  forbidding  spitting  on 
sidewalks,  in  public  buildings,  in  cars,  etc.  It  is  then  most  important 
that  every  one,  young  or  old,  should  realize  clearly  the  dangers  of  indis- 
criminate spitting,  and  one’s  duty  in  seeing  that  this  disgusting  habit 
is  stopped.  Tuberculosis  may  be  spread  in  a small  measure  in  other 
ways:  by  means  of  germs  from  tuberculous  cattle,  which  find  their 
way  into  milk  or  meat;  but  this  factor  is  such  a small  one  that  it  may 
properly  be  passed  over  with  a very  few  words. 

While  we  should  realize  that  an  untrained,  ignorant  and  careless 
consumptive  is  a danger  to  the  community,  we  should  also  remember 
and  constantly  teach  that  the  trained  consumptive  who  is  careful  about 
his  sputum  and  cleanly  in  his  habits  ceases  to  be  dangerous,  and  may 
live  among  us  without  jeopardizing  the  health  of  others.  It  is  very 
important  that  this  distinction  should  be  made  clear,  and  that  every 


J 


18 


effort  should  be  made  to  eradicate  the  stigma  which  in  present  times 
often  rests  upon  the  consumptive,  no  matter  how  careful  and  well 
trained  he  is. 

Y. 

Tuberculosis  is  not  hereditary;  it  is  the  tendency  which  is  inherited, 
but  not  the  disease  itself.  In  other  words,  consumptive  parents  may 
have  children  who  are  naturally  of  a poor  constitution,  with  weak  lungs, 
flat  chests,  and  little  or  no  power  to  resist  infection.  Children  in  such 
families  should  be  brought  up  with  the  utmost  care,  and  should  be 
given  the  maximum  amount  of  fresh  air  and  sunlight.  The  training  of 
their  minds  should  be  sacriflced,  if  need  be,  in  order  that  their  bodies 
may  be  developed  to  the  highest  possible  standard  of  health.  It  is  for 
such  children  as  these  that  there  have  been  founded  in  Germany  the 
so-called  “ forest  schools,”  where  the  children  of  tuberculous  parents 
and  all  those  children  who  are  weak  and  run  down  and  liable  to  con- 
tract this  disease  are  sent.  There  they  go  to  school  practically  out  of 
doors,  and  are  trained  in  the  best  habits  of  hygiene  and  proper  living. 
Such  a school  as  this  has  recently  been  opened  in  Providence,  R.  I., 
and  others  are  planned  for  this  State. 

We  should  endeavor  to  teach  children,  first,  that  spitting  is  a dan- 
gerous as  well  as  a disagreeable  habit;  and  second,  that  the  best  way  to 
avoid  consumption  is  to  so  live  that  we  are  always  in  a healthy  con- 
dition, so  that  we  can  resist  the  haiinful  action  of  any  germs  that  may 
find  their  way  into  our  lungs  or  stomachs.  We  should  teach  children 
the  importance  of  fresh  air,  good  food  and  cleanliness,  and  a proper 
amount  of  sleep. 

In  regard  to  fresh  air:  m far  too  many  instances  mothers  have  a 
positive  dread  of  open  windows  and  of  draughts.  It  is,  however,  very 
important  that  rapidly  growing  children  should  have  as  much  fresh 
air  as  possible.  This  should  be  taught  in  a practical  way  in  the  school- 
room itself,  by  using  every  possible  means  for  good  ventilation,  by 
opening  the  windows  wide  during  all  recess  intervals,  and  by  inteiTupt- 
ing  hours  of  study  by  short  intermissions  during  which  the  children 
are  given  breathing  exercises  with  the  windows  wide  open.  The  fact 
should  be  emphasized  that  night  air  is  not  dangerous.  The  fact  that 
we  are  all  spending  one-third  of  our  lives  in  sleep,  and  that  during  this 
one-third,  which  is  the  period  used  for  building  up  the  body  and  making 
good  the  losses  sustained  during  the  day^s  work,  it  is  most  important  that 
the  body  should  have  fresh  air  in  large  amounts,  should  be  taught.  A 
large  amount  of  sleep  in  the  growing  period  is  important.  All  this 
should  be  emphasized. 

The  question  of  proper  food  should  be  considered.  The  use  of  tea 
and  coffee  and  other  stimulants  among  children,  especially  of  the  poorer 
classes,  is  extremely  common,  and  does  a great  deal  of  harm.  Tlie  dan- 
gers of  this  should  be  taught. 

The  importance  of  bathing  should  be  made  clear.  Children,  and 


< 


19 


through  them  their  parents,  should  be  made  to  see  that  the  morning 
bath  is  not  only  for  cleanliness,  but  also  to  stimulate  the  body  and 
mind  for  the  work  of  the  day.  Every  child  should  be  faught  as  soon 
as  possible  to  take  a sponge  bath  in  a warm  room  every  morning.  The 
proper  care  of  the  teeth  should  be  emphasized,  and  the  dangers  of  neg- 
lecting to  care  for  the  teeth  constantly  impressed  upon  the  children. 

There  should,  whenever  possible,  be  active  co-operation  between  the 
teachers  and  medical  inspectors;  for  the  teacher,  who  sees  the  children 
constantly,  can  note  the  signs  of  failing  health  far  more  accurately  in 
many  cases  than  the  physician,  who  sees  the  child  only  occasionally. 

VI. 

The  treatment  of  consumption  first  of  all  is  by  so  living  that  the 
body  does  not  acquire  the  disease;  therefore,  the  ideal  method  of  treat- 
ment is  by  prevention.  This,  however,  is  not  possible  in  every  case,  and 
there  are  unfortunately  a great  many  people,  as  has  been  shown,  who 
have  this  disease,  for  whom  active  measures  in  curing  it  or  stopping 
its  progress  must  be  taken.  Treatment  is  not  by  means  of  drugs  or 
medicines.  Especially  one  should  avoid  patent  medicines  and  advertised 
cures  of  all  kinds.  Treatment  consists  in  giving  the  patient  fresh  air 
day  and  night,  proper  food  at  the  proper  time,  and  rest.  This  is 
done  either  in  the  home  or  in  institutions  built  for  this  purpose,  called 
tuberculosis  sanatoria.  Massachusetts  was  the  first  State  in  this  country 
to  have  a State  sanatorium.  The  Massachusetts  State  Sanatorium  is 
a large  institution,  which  holds  three  hundred  and  fifty  patients,  situated 
in  the  center  of  the  State,  in  Rutland.  Here  patients  in  the  early  stage 
of  consumption,  which  is  the  curable  stage,  are  taught  how  to  live  out 
of  doors  in  comfort;  how  to  sleep  out  of  doors  at  night,  or  in  open-air 
wards  or  rooms  winter  and  summer;  what  food  they  must  eat;  the 
amount  of  exercise  or  rest  they  must  take;  and  the  precautions  they 
must  use  in  earing  for  their  sputum,  to  avoid  giving  others  this  disease. 
Such  sanatoria  exist  in  most  civilized  countries  to-day,  and  more  are 
being  established  every  year.  The  average  length  of  stay  is  six  months 
to  a year.  From  sixty  to  seventy  per  cent,  of  those  in  the  early  stage  of 
the  disease  leave  the  sanatorium  at  the  end  of  this  time  apparently 
cured. 

The  fact  should  be  emphasized  that  it  is  no  longer  considered  neces- 
sary for  a consumptive  to  go  to  a different  climate  or  to  some  distant 
place  in  order  to  get  cured  of  the  disease,  for,  although  certain  climates 
are  of  value,  consumption  is  being  cured  in  New  England  every  day. 

It  is  important  to  remember,  however,  that  but  a small  percentage  of 
these  consumptives  are  in  a position  financially  or  otherwise  to  go  to 
a sanatorium  for  treatment.  A gTeat  majority  of  sufferers  from  this 
disease  must  be  taught  how  to  live  in  their  own  homes;  and  at  present 
the  so-called  home  treatment  of  consumption  is  meeting  with  a great 
deal  of  attention. 


) 


20 


Teachers  of  our  public  schools  have  a great  opportunity  to  instruct 
the  children  with  whom  they  come  in  contact,  young  and  old,  in  the 
principles  of  tliis  treatment ; and  it  is  important  to  always  bear  in  mind 
that  fresh  air  night  and  day,  sunlight,  cleanliness,  bathing,  plenty  of 
plain,  nourishing  food,  are  the  things  on  which  the  treatment  of  con- 
sumption is  based;  and,  further  than  this,  that  these  are  the  essential 
conditions  in  obtaining  and  preserving  good  health  and  in  avoiding  a 
gTeat  many  other  kinds  of  diseases.  The  actual  details  of  the  open- 
air  treatment  of  consumption  may  well  be  left  to  the  physician  or  nurse. 

VII. 

It  is  important  that  teachers  should  realize  that  the  earliest  sign 
of  consumption  is  not  necessarily  the  so-called  hacking  cough,  hemor- 
rhage from  the  lungs,  or  the  presence  of  night  sweats  and  fever.  These 
frequently  do  not  appear  until  comparatively  late  in  the  disease.  The 
earliest  signs,  in  children  especially,  are  those  of  failing  health,  from 
whatever  cause.  In  the  first  place,  the  teacher  should  be  told  or  should 
find  out  what  children  in  the  class  have  consumption  in  their  family, 
and  should  give  special  attention  to  these  children.  Loss  of  appetite, 
weakness,  languor,  listlessness,  are  among  the  early  signs.  Pallor, 
marked  anaemia,  loss  of  weight,  excessive  emaciation,  the  presence  of 
enlarged  glands  in  the  neck,  are  indications  that  there  is  something 
wrong.  If  in  addition  to  this  there  is  a cough,  with  or  without  any 
sputum,  the  child  should  most  certainly  be  examined  by  a physician. 

VIII. 

The  campaign  against  tuberculosis  in  Massachusetts  is  along  two  lines ; 
first,  that  which  is  being  done  by  sanatoria  and  hospitals;  second,  that 
which  is  being  done  outside  of  these  institutions  by  physicians,  boards 
of  health,  anti-tuberculosis  associations,  etc.,  in  teaching  people  how  to 
live  in  their  own  homes. 

At  present  Massachusetts  has  certain  State  institutions,  such  as  the 
State  Sanatorium  at  Rutland  for  early  eases,  the  three  hospitals  for  ad- 
vanced cases  which  are  being  planned  by  the  Massachusetts  Commission 
on  Hospitals  for  Consumptives,  and  numerous  private  institutions.  In 
addition  to  this,  and  of  still  more  importance,  is  the  work  which  is  being 
done  by  the  medical  profession  throughout  the  State  and  by  the  various 
anti-tuberculosis  associations,  lay  and  medical,  which  have  been  formed 
in  all  of  the  large  cities  and  in  many  of  the  smaller  cities  and  towns  of 
Massachusetts. 

It  is  by  these  agencies  that  the  prevention  and  control  of  tuberculosis 
is  being  accomplished.  By  means  of  tuberculosis  clinics  and  district 
nurses  we  are  finding  out  the  innumeral)le  cases  of  consumption  in  the 
homes,  in  the  tenements  and  in  the  factories  of  our  State.  The  early 
cases  are  urged  to  go  to  the  State  Sanatorium  at  Rutland ; projier 
hospital  accommodation  is  ol)tained  for  the  advanced  cases,  or  they 
are  taught  how  to  live  in  their  own  homes.  The  masses  of  the  people 


21 


are  educated  by  means  of  lectures,  exhibits,  cards  and  signs,  etc.; 
boards  of  health  are  stimulated  to  take  proper  measures  as  regards 
disinfection;  and  physicians  are  persuaded  to  report  their  cases  of 
consumption  as  they  do  their  cases  of  scarlet  fever.  Most  important 
of  all,  the  general  public  is  aroused  to  realize  the  importance  of  the 
subject. 

One  of  the  most  efficient  means  of  instructing  the  public,  and  school 
children  as  well,  in  regard  to  tuberculosis,  is  by  means  of  the  travelling 
tuberculosis  exhibit  which  goes  from  city  to  city  throughout  the  State. 
It  is  very  important  that  when  this  exhibit  appears  arrangements  should 
be  made  by  which  teachers  and  school  children  of  all  grades  should 
attend,  and  receive  definite  instruction  as  to  what  the  various  charts, 
photographs,  models,  etc.,  mean.  Such  an  exhibit  will  be  found  an  ob- 
ject lesson  of  verj^  great  importance,  and  a means  of  emphasizing  the 
points  which  have  been  given  in  previous  instruction  in  the  schools. 

IX. 

The  following  books,  or  most  of  them,  can  be  found  in  the  public 
libraries,  in  the  travelling  library  of  the  Massachusetts  Federation  of 
Women^s  Clubs,  or  should  be  provided  by  the  local  anti-tuberculosis 
association,  and  some  at  least  should  be  provided  by  the  school  com- 
mittees for  the  use  of  the  teachers.  Further  information  can  be  ob- 
tained at  any  time  by  applying  to  the  Massachusetts  Commission  on 
Hospitals  for  Consumptives,  3 Joy  Street,  Boston,  or  to  the  Boston 
Association  for  Relief  and  Control  of  Tuberculosis,  4 Joy  Street, 
Boston.  In  almost  every  ease  local  physicians  can  give  additional  in- 
formation. 

List  of  Books. 

“ Tuberculosis  as  a Disease  of  the  Masses,  and  how  to  combat  it,”  by 
Dr.  S.  A.  Knopf.  (This  can  be  obtained  from  “ Charities  and  the  Com- 
mons,” 105  East  22d  Street,  New  York,  at  25  cents  a copy.) 

“ The  Cause  and  Prevention  of  Consumption,”  a circular  issued  by  the 
niinois  State  Board  of  Health. 

“ Consumption  and  Civilization,”  by  John  B.  Huber,  a large  book,  going 
into  very  minute  detail  on  this  subject.  (It  can  probably  be  found  in  the 
public  libraries,  and  can  be  bought  at  any  large  book  store.) 

“ The  Prevention  and  Cure  of  Tuberculosis,”  a collection  of  articles  of  a 
popular  character  on  the  subject  of  tuberculosis,  by  the  leading  men  in  this 
subject  in  this  country;  compiled  by  Joseph  R.  Long;  published  by  H.  M. 
Brinker,  Denver.  This  is  an  excellent  series  of  essays,  covering  the  whole 
ground  very  completely,  and  can  be  secured  of  any  bookseller. 

Pamphlet  of  information  on  the  subject  of  tuberculosis,  issued  by  the 
Boston  Association  for  Relief  and  Control  of  Tuberculosis,  which  can  be 
obtained  on  application  at  the  office  of  the  Association  at  a nominal  price. 

Several  school  text-books  on  physiology  and  hygiene  contain  valuable 
chapters  on  tuberculosis.  Information  concerning  these  may  be  ob- 
tained from  the  publishers. 


22 


c 


Printed  Pules  of  Health. 

The  following  rules  of  health  have  been  prepared  bj  the  Edu- 
cational Department  of  E'ew  Jersey,  and  furnished  to  all  the 
schools : — 

How  TO  KEEP  WELL  AND  PREVENT  CONSUMPTION. 

Air. 

Fresh  air  and  sunshine  are  necessary  to  good  health. 

Cold  or  damp  fresh  air  does  no  harm  if  the  skin  is  kept  warm. 
Night  air  is  as  good  as  day  air. 

Breathe  only  through  your  nose. 

Avoid  hot,  .crowded,  dusty,  dark  or  damp  rooms. 

Breathe  deeply  and  throw  back  the  shoulders  frequently. 


Food. 

Live  on  plain  food,  and  eat  regularly. 

Eat  slowly,  chew  thoroughly,  and  avoid  fried  food. 

Drink  water  freely  (not  iced). 

Have  your  own  cup  if  drinking  fountains  are  not  provided  at  school. 
Exercise  and  Rest. 

Regular  exercise  is.  essential  to  good  health. 

Go  to  bed  early,  and  sleep  with  the  windows  open. 

Never  sleep  in  a damp  bed. 


Clothing. 

Wear  only  loose  clothes. 

Wear  no  more  clothing  than  you  need  for  warmth. 

Never  sit  with  wet  feet  or  in  damp  clothing. 

Cleanliness. 

Consumption  and  other  diseases  are  spread  by  careless  spitting. 

Spittle  on  the  floors  of  rooms,  halls,  stores  and  cars  will  certainly  be 
breathed  in  the  form  of  dust. 

Keep  clean.  Wipe  and  dry  the  body  quickly  every  day. 

Keep  your  finger  nails  clean,  and  wash  your  hands  and  face  before 
you  eat. 

Clean  your  teeth  after  each  meal  and  before  going  to  bed. 

Never  hold  money,  pencils,  pins  or  other  things  in  your  mouth. 

Never  lick  your  fingers  while  turning  the  pages  of  a book  or  count- 
ing money. 

All  children  should  obsen^e  the  preceding  rules,  both  for  their  own 
sake  and  for  the  sake  of  others.  They  are  necessary  safeguards  against 


( 


23 


other  dangerous  diseases  besides  consumption.  Nearly  all  children’s 
diseases  are  infectious. 

The  foregoing  rules  have  been  approved  by  the  State  Board  of 
Health  and  the  State  Board  of  Education. 

Teachers  are  requested  to  make  them  as  effective  as  possible. 

C.  J.  Baxter,  State  Superintendent. 

Trenton,  N.  J. 


More  specific  than  these  are  the  rules  prepared  by  Dr.  S.  A. 
Knopf  of  Kew  York  City,  entitled  Simple  Rules  for  School 
Children  to  prevent  Tuberculosis.’’ 

Do  not  spit  except  in  a spittoon,  a piece  of  cloth  or  a handkerchief 
used  for  that  purpose  alone.  On  your  return  home  have  the  cloth 
burned  by  your  mother,  or  the  handkerchief  put  in  water  until  ready 
for  the  wash. 

Never  spit  on  a slate,  floor,  playground  or  sidewalk. 

Do  not  put  your  fingers  into  your  mouth. 

Do  not  pick  your  nose  or  wipe  it  on  your  hand  or  sleeve. 

Do  not  wet  your  fingers  in  your  mouth  when  turning  the  leaves  of 
books. 

Do  not  put  pencils  in  your  mouth  or  wet  them  with  your  lips. 

Do  not  hold  money  in  your  mouth. 

Do  not  put  pins  in  your  mouth. 

Do  not  put  anything  in  your  mouth  except  food  and  drink. 

Do  not  swap  apple  cores,  candy,  chewing  gum,  half-eaten  food, 
whistles,  bean  blowers,  or  anything  that  is  put  in  the  mouth. 

Peel  or  wash  your  fruit  before  eating  it. 

Never  sneeze  or  cough  in  a person’s  face.  Turn  your  face  to  one 
side  or  hold  a handkerchief  before  your  mouth. 

Keep  your  face,  hands  and  finger  nails  clean.  Wash  your  hands 
with  soap  and  water  before  each  meal. 

When  you  don’t  feel  well,  have  cut  yourself,  or  have  been  hurt  by 
others,  do  not  be  afraid  to  report  to  the  teacher. 

Keep  yourself  just  as  clean  at  home  as  you  do  at  school. 

Clean  your  teeth  with  tooth-brush  and  water,  if  possible,  after  each 
meal;  but  at  least  on  getting  up  in  the  morning  and  on  going  to  bed 
at  night. 

Do  not  kiss  any  one  on  the  mouth  or  allow  anybody  to  do  so  to  you. 

Learn  to  love  fresh  air,  and  learn  to  breathe  deeply  and  do  it  often. 

Out-door  Class  in  Boston. 

The  following  account  of  an  effort  to  provide  healthful  con- 
ditions for  school  children  exhibiting  signs  of  incipient  tuber- 
culosis has  been  furnished  by  Mr.  Walter  E.  Kruesi,  secretary 


) 


24 


of  the  Boston  Association  for  the  Belief  and  Control  of  Tuber- 
culosis : — 

Examination  of  the  families  of  persons  applying  at  the  Tuberculosis 
Clinics  in  Boston  was  started  at  the  instance  of  the  Boston  Associa- 
tion for  the  Relief  and  Control  of  Tuberculosis  in  January,  1907. 
The  first  1,200  children  examined  revealed  100  cases  of  tuberculosis, 
mostly  incipient.  These  children  were  attending  the  regular  public 
schools.  As  the  incipient  cases  are  not  contagious,  they  were  not  a 
source  of  danger  to  their  schoolmates,  but  their  school  records  show 
that  they  were  too  unwell  to  absorb  the  education  which  was  provided. 
This,  therefore,  represented  a waste  of  thousands  of  dollars  per  year. 
FurtheiTuore,  the  average  school  ventilation  conditions  and  the  pres- 
sure of  the  school  work  was  distinctly  detrimental  to  them.  There  was 
absolutely  no  institution  or  other  provision  for  such  children  in  this 
State.  Turning  to  find  out  what  others  were  doing,  the  Boston  Asso- 
ciation studied  the  forest  schools  provided  for  this  class  of  cases  by 
many  of  the  German  cities  and  the  outdoor  schools  provided  in  England. 
In  these  schools  the  children  admitted  are  sent  every  day  to  the  open 
country  nearest  their  homes,  and  are  there  provided  with  proper  clothing 
and  school  benches  set  down  in  the  open.  During  storms  the  benches 
are  moved  under  a canopy  roof.  There  is  no  further  shelter  The 
children  are  properly  fed  during  the  day,  and  the  curriculum  is  modi- 
fied by  the  introduction  of  therapeutic  exercises,  rest  periods  and 
otherwise,  as  indicated  by  scientific  study  of  the  needs  of  the  group. 
The  association’s  secretary  proposed  last  winter  that  a similar  school 
should  be  organized  in  Boston.  Finally  on  the  16th  of  July  it  was 
opened  as  a day  sanatorium  and  school  of  outdoor  life  on  the  grounds 
of  the  proposed  Robert  Brigham  Hospital,  Parker  Hill,  Roxbury.  This 
situation  had  been  previously  used  to  good  effect  for  an  adult  day  san- 
atorium. A simple  building  was  built,  containing  two  dressing  rooms 
and  lavatory  with  a large  shower  bath  between,  an  open  kitchen, 
pantry,  and  platform  for  a large  tent  to  be  used  for  a shelter  in  storms 
and  as  a dining  room.  Three  10  by  12  tents  were  provided  for  the 
cook,  handy  man  and  tools  and  supplies.  A garden  3 by  7 feet  was 
laid  out  for  each  team  of  two  children.  There  were  also  three  central 
flower  gardens.  In  these  were  planted  seven  varieties  of  vegetables  and 
ten  varieties  of  flowers.  Small  plants  were  put  in  because  of  the  late- 
ness of  the  season,  and  in  order  to  give  the  children  an  encouraging 
start. 

The  schedule  of  the  day  began  with  assembly  and  the  raising  of 
the  national  and  health  flags,  then  ablutions,  breakfast,  brushing  of 
teeth.  After  an  hour’s  work  in  the  garden  and  an  hour’s  class  in 
study  of  the  lessons  of  the  need  of  living  things  for  oxygen,  good 
food,  sunlight,  elbow  room,  etc.,  they  again  became  active  in  free 
play.  Washing  up  for  dinner  quieted  them,  and  after  again  brushing 


< 


the  teeth,  all  were  required  to  rest  or  sleep  for  an  hour.  The  after- 
noon routine  was  similar.  At  the  end  of  eight  weeks  all  of  the  chil- 
dren had  gained  in  weight,  had  made  marvelous  improvement  in  ap- 
pearance and  manners,  while  the  tuberculosis  of  8 had  been  definitely 
arrested.  Every  garden  had  succeeded  in  every  crop.  One  child’s 
family  had  moved  out  of  the  worst  part  of  town  to  good  quarters, 
while  others  had  materially  improved  their  surroundings. 

Lest  the  gi’eat  gain  which  had  been  made  should  be  lost,  the  school 
board  was  requested  to  organize  a special  class,  made  up  of  these 
children  and  others  admitted  to  take  the  place  of  the  discharged.  An 
especially  fitted  teacher  was  selected  for  the  work,  and  is  now  con- 
ducting it  in  the  unheated  tent.  To  provide  against  the  exposure, 
every  child  is  given  a waterproof  canvas  bag  lined  with  blanket.  Each 
child  has  also  been  provided  with  an  especially  warm  overcoat  and 
other  necessary  clothing.  The  teacher  reports  that  the  children  are 
making  satisfactory  progress  in  keeping  up  with  the  work  which  they 
ought  to  do  were  they  in  the  regular  school.  The  city  of  Boston  is  mak- 
ing an  effort  to  provide  the  school  with  a proper  building  for  shelter 
duiing  bad  weather,  and  in  order  that  the  efforts  already  so  well  begun 
may  be  placed  on  a safe  basis  for  continued  development. 

Playgrounds. 

The  playgrouiid  movement  is  a part  of  the  general  effort  to 
improve  the  conditions  for  the  physical  and  mental  growth  of 
children,  and  it  seems  now  to  be  the  most  popular  part. 

In  1908  the  Legislature  passed  the  following  act,  knotvn  as 
chapter  513,  Acts  of  1908 : — 

An  Act  to  provide  for  public  playgrounds  in  certain  cities  and 

TOWNS. 

Section  1.  Every  city  and  town  in  the  commonwealth  having  a pop- 
ulation of  more  than  ten  thousand,  accepting  the  provisions  of  this  act 
shall,  after  the  first  day  of  July  in  the  year  nineteen  hundred  and  ten, 
provide  and  maintain  at  least  one  public  playground  conveniently  lo- 
cated and  of  suitable  size  and  equipment,  for  the  recreation  and  physical 
education  of  the  minors  of  such  city  or  town,  and  at  least  one  other 
plaj^ground  for  every  additional  twenty  thousand  of  its  population. 

Section  2.  Cities  and  towns  may  appoint,  and  determine  the  com- 
pensation of,  a qualified  supervisor  of  each  playground,  who  shall  direct 
the  sports  and  exercises  thereon. 

Section  3.  In  cities  and  towns  where  the  provisions  of  this  act  are 
not  already  satisfied,  land  for  the  purpose  aforesaid  may  be  taken,  and 
the  money  necessary  to  pay  for  such  land  may  be  raised  in  accordance 
with  sections  nineteen,  twenty  and  twenty-one  of  chapter  twenty-eight 


26 


of  the  Revised  Laws;  and  any  land  owned  by  the  city  or  town  may  be 
set  aside  by  vote  of  the  city  council,  or  of  the  board  of  selectmen,  for 
the  purposes  of  this  act. 

Section  4.  In  cities  and  towns  which  have  a population  of  more 
than  ten  thousand,  and  which  have  not  already  satisfied  the  provisions 
of  this  act,  the  following  question  shall  be  placed  on  the  official  ballot 
at  the  next  city  or  town  election : — Shall  chapter  of  the 

acts  of  the  year  nineteen  hundred  and  eight,  requiring  certain  cities  and 
towns  to  provide  public  playgrounds,  be  accepted  by  this  (city  or  town)  ? 

Section  5.  This  act  shall  take  effect  in  any  city  or  town  to  which 
it  applies  upon  its  acceptance  by  a majority  of  the  voters  voting  as 
aforesaid. 

Under  the  referendum  provisions  of  this  act  it  was  subjected 
to  popular  vote  at  the  December  elections  in  25  cities.  The 
vote  was  as  follows : — 


Yes. 

No.  1 

Yes. 

i No. 

! 

Beverly, 

2,139 

703 

Melrose, 

1,386 

452 

Brockton,  . 

7,468 

1,046 

New  Bedford. 

7,107 

1,187 

Chicopee, 

1,445 

754 

Newburyport, 

1,746 

770 

Everett, 

2,102 

248 

North  Adams, 

1,217 

1,383 

Fall  River,  . 

10,940 

1,484 

Northampton, 

1,140 

1,236 

Fitchburg,  . 

3,539 

761 

Pittsfield, 

3,783 

727 

Gloucester,  . 

2,489 

920 

Quincy, 

3,002 

933 

Haverhill,  . 

4,825 

1,116 

Salem, 

5,129 

606 

Holyoke, 

5,047 

787 

Springfield, 

10,342 

1,006 

Lawrence,  . 

7,533 

1,406 

Taunton, 

4,181 

910 

Lowell, 

10,283 

2,424 

Woburn, 

1,994 

437 

Lynn, 

11,122 

1,083 

Worcester,  . 

13,626 

4,557 

Marlborough, 

2,064 

463 

These  figures  are  mainly  from  newspapers,  and  subject  to 
slight  errors. 

The  acceptance  of  this  act  is  only  the  beginning.  There 
will  be  needed  a campaign  of  education  to  secure  under  tlie 
law  a sufficient  number  of  grounds  suitably  located,  adequately 
equipped  and  properly  supervised. 

The  supervision  should  be  by  the  school  authorities  or  some 
other  non-political  organization. 


27 


School  Instruction  in  Hygiene. 

While  the  public  under  the  medical  inspection  law  is  doing 
so  much  for  the  schools,  the  question  is  a reasonable  one,  What 
are  the  schools  doing  in  return  ? ’’  It  were  foolish  to  go  on 
year  after  year  hunting  for  troubles  and  always  finding  them, 
spending  public  and  private  money  in  curing  defects,  without 
undertaking  to  go  deeper  and  strike  at  the  roots. 

We  ought  to  be  able  to  look  forward  to  a reduction  in  the 
number  of  disabled  children,  and  to  the  eradication  of  many  if 
not  of  most  of  the  diseases  and  defects. 

The  physical  defects  and  disabilities  from  which  the  children 
are  suffering  are  in  the  main  due  to  ignorance  of  the  laws  of 
health.  Parental  neglect  is  not  wilful. 

The  relation  to  health  of  personal  cleanliness  and  household 
sanitation,  of  food  and  air  and  light  and  sleep,  is  very  imper- 
fectly understood. 

Public  education  can  have  no  worthier  end  than  to  promote 
public  health.  To  do  this  effectively,  the  much-neglected  and 
much-abused  study  of  physiology  and  hygiene  will  have  to  be 
given  a more  prominent  place  in  the  curriculum  of  all  schools. 
Even  the  three  P’s  ” are  not  more  essential. 

To  the  prejudice  created  by  the  unwise  efforts  to  confine  all 
the  school  instruction  in  physiology  to  the  effects  of  alcohol  and 
tobacco  is  due  much  of  the  neglect.  There  is  needed  everywhere 
an  increased  amount  of  time  for  the  study,  more  sympathetic 
and  judicious  instruction,  and  a more  studied  effort  to  bring 
the  schools  and  the  parents  into  co-operation  for  the  forming 
of  better  habits  by  the  children,  and  for  more  sanitary  conditions 
in  the  homes.  Such  study  and  such  effort  will  make  the  tem- 
perance instruction  not  less  but  more  effective. 


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